Submitting GAP bills On October 1, 2003, The Centers for Medicare & Medicaid Services (CMS) implemented new edits. Those edits required long-term care hospitals, skilled nursing facilities (SNFs), and inpatient hospitals not subject to the Inpatient Prospective Payment System to submit monthly bills. Pub 100-4 Chapter One Section 50.2 reinforces when those services are to bill:
Medicare also requires SNFs to submit claims for Part A beneficiaries who reside in their facilities. This applies to noncovered as well as covered stays. No pay discharge claims are those noncovered Part A claims that MUST be submitted to your fiscal intermediary for the purpose of tracking benefit periods. These claims represent the period from the day after the last covered SNF Part A day to the day of death, discharge, or transfer to another inpatient facility. Failure to submit discharge claims for the beneficiary who resides in a SNF can result in incorrectly assigned Part A benefits on the common working file (CWF). Any gap of 60 days on the CWF without the presence of a Part A claim, even a noncovered one, establishes a new benefit period upon admission for an inpatient hospital stay. This can result in the creation of inappropriate benefit periods. Submitting a gap bill not only satisfies CMS’s mandates for monthly billing but also prevents the creation of inappropriate benefit periods. Coding the GAP bill When the beneficiary’s benefits are exhausted and the beneficiary continues to receive skilled care include occurrence code A3 in FL 32, 33, 34, or 35. This code identifies the day that benefits exhausted. When the beneficiary’s benefits are exhausted and the beneficiary drops to a noncovered level of care include occurrence code 22 in FL 32, 33, 34, or 35 to indicate the date covered care ended. When the beneficiary continues to receive benefits and the beneficiary drops to a noncovered level of care include occurrence code 22 in FL 32, 33, 34, or 35 to indicate the date covered care ended. When it is determined that the beneficiary has dropped to a noncovered level of care, a denial notice must be given in writing and signed by the beneficiary or their legal representative. If the beneficiary or their legal representative believes that Medicare will cover the services, they may request a claim be submitted to the intermediary for review. This type of claim is called a demand bill.
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